The Bristol Health Partners'
HIT Model – How does it work?
Sabi Redwood on behalf of NIHR CLAHRC West
#CLAHRC_West
clahrc-west.nihr.ac.uk
Precursor to an evaluation
• Developing a ‘theory of change’ for wholesystem working to improve service delivery
and health outcomes
• Understanding how and why something
actually work is vital for the purpose of
evaluation
• Clearly linking observed effects to the changes
• Generalising findings to models of the same
type
Logic between activities and expected
results
Inputs
Processes
Outputs
Outcomes
Impacts
Study aims
1. Retrospectively to assemble the ‘theory of
change’ underlying the HIT model
2. To provide fine-grained description of
mechanisms by which any intended
outcomes are thought to be achieved
3. To inform the development of a formal
evaluation strategy for the HITs
Methods
• Documentary analysis of anonymised Bristol
Health Partners’ documents related to HITs
and their development (approx. 140)
– Data collection period June 2010 - August 2014
• Interviews with key informants involved in
developing the HIT model (11)
– Data collection December 2014 – February 2015
Analysis
• Constant Comparative Method involving initial
coding, the forming and refining of categories,
searching for negative evidence, and
comparison across each stage of the analytic
development of explanatory concepts
• Data management, coding and categorisation
supported by QRS NVivo software
Overarching themes
• ‘Whole system’ engagement – WHO? Process/Inputs
• Collaboration – HOW? Process/Outputs
• Integration – WHAT? Outcome/Impact
• Innovation – WHAT? Outcome/ Impact
‘Whole system’ engagement (1)
• Refers to the process of actively seeking to
engage all organisations and people who play a
part in the health and social care economy
related to LTCs or PH of the HIT being formed
–
–
–
–
–
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Provider organisations
Commissioning organisations
Professionals/ staff in these organisations
Public(s) and service users/carers
Other public sector organisations (e.g. LAs, H&WBs)
Non-NHS/social care organisations (e.g. TSOs,
industry)
‘Whole system’ engagement (2)
• Facilitated through the process of becoming a HIT
– Structured application process focused thinking on who
should be involved in tackling the issue (LTCs/ PH)
– Iterative assessment process in which applicants may be
asked to modify their proposals after initial assessment
– Feedback to applicants included suggestions for widening the
circle of engagement, often the less obvious
• Joint strategic PPI across several stakeholders
‘Whole system’ engagement (3)
‘I would hear commissioners saying “this is
brilliant”, you know “I’m able to have
conversations with people that I could never
access before and we can get like-minded people
in the room together and we all want the same
thing … and I used to sit there thinking “this is
what it’s all about, this is actually what we were
trying to create”.
(Participant 9, clinical academic)
Collaboration (1)
• Refers to the development of methods that
enable partnership working and co-production,
involving
– Establishing structures and processes that facilitate
collaboration
– Co-creating scientific questions that people in
positions to enact change want answers to
– Responsiveness to information/ knowledge needs,
and knowledge mobilisation for decision making
– Having visibility – being the ‘place to go’ for evidence
– Leadership and negotiation skills
Collaboration (2)
• Breakdown of professional, organisational and
sectorial boundaries and silos
• Mechanism for addressing translational/
implementation gap
• HIT sponsorship at senior level as key
component of organisational commitment to
provide resources and proactively facilitating
collaboration
Collaboration (3)
‘… without sounding somewhat simple about it, you
know, relationships are the most important thing in
order to move anything together in a partnership.
So the aspect of one area that has been successful
was that the relationship with the commissioners
was strong in the sense of having a common
ideology. And mutual respect of each other’s
tensions to deliver this, so when you understand
that, you can actually find a common goal that
would achieve.’
(Participant 5, HIT director, clinical academic)
Integration (1)
• Refers to a range of activities which are
brought together to maximise benefit,
involving
– Existing collaborations
– Service delivery and research
– Biomedical and population based/ community
research
– Data linkage and data intelligence
– (Integration of health and social care services)
Integration (2)
• Developing / piloting integrated assessment
clinics and one-stop-shops
• Providing integrated information support and
advice to GPs to facilitate implementation of
pathways
• Bringing together and addressing gaps in data
sets – JSNA, research, clinical – to inform
service design and delivery
(HIT documents)
Integration (3)
So - moving on beyond the language of collaboration and
(…) towards a position where organisations are operating
in a framework which will encourage them to make
decisions on the basis of system benefit and not
organisational benefit: that’s a journey we’re still on, but I
think that the fact that we’ve begun it and we’ve made
that change in terms of language and people’s collective
collaboration is a very strong legacy of [the HIT
development work] and the HITs are important in that
regard because they are a material demonstration of how
that will work in practice. You can say to people “This is
what it means. Look at the work that they’re doing. This is
what it can mean in practice.”
(Participant 8, senior manager)
Innovation (1)
• Refers to novel ways of delivering services or
interventions through the introduction or
application of new approaches, usually to
improve quality and decrease costs
– Biotechnology products and IT solutions
– Collaboration with industry
– New roles and/or organisational models
– New insights through data linkage and data
intelligence
Innovation (2)
• The development of novel ‘near patient testing’
technology: expanded links with industrial
partners and working with them to develop novel
near patient testing. This will facilitate rapid
diagnostics in those individuals in which a swift
diagnosis can assist in deciding the treatment
option
• Use of technology to increase access to services
• Piloting of new interventions and services
• Data linkage and data sharing agreements
(HIT documents)
Innovation (3)
‘The hope is that [the HIT work] will potentially
open up new ways to think about the sorts of
interventions that will have real impact. So
spotting an unknown correlation might unlock a
whole different sort of area of policy
interventions that we just don’t focus on at the
moment.’
(Participant 8, senior manager)
What HITs do
• HITs harness the benefits of collective enquiry
through the inclusion of all stakeholders,
including patients and the public
• HITs provide a legitimate ground for
negotiation, finding practical solutions and
compromise
• HITs facilitate collaborative work to define,
refine, generate and implement evidence
HITs in relation to PH and service
delivery (1)
• Provide focus for key health challenges
• Unique model of collaboration and knowledge
mobilisation
• Provide pathway from evidence or research to
implementation in practice
HITs in relation to PH and service
delivery (2)
• Provide mechanism through which lessons
from research can be used quickly, effectively
and systematically to improve services
• Facilitate relationships with WEAHSN to roll
out innovation and exploit potential for
wealth creation
• Cross-HIT collaboration and learning
HITs in relation to research (1)
• Close fit with local and regional strengths
• HITs provide opportunities for multistakeholder research to engage a wide range
of perspectives
• Generate scope for wider genre of research
beyond biomedical paradigm
• Facilitate inclusive research culture
• Increase research capability and capacity
HITs in relation to research (2)
• Need for negotiation and brokering across
multiple agendas and perspectives
• Existing collaborative relationships provide
‘competitive edge’ in research funding
applications
• Cross-HIT collaboration and learning
Simple logic model for HITs
Inputs:
- Application
process
- Central
resources
- Organisa
tional
resources
Impacts:
Outputs:
Processes:
- Whole system
engagement
- Collaboration
What HITs do
- Pathways
- Coordination
& liaison
- Work streams
- Research
- Service
evaluation
Outcomes:
System-level
- Integration
- Innovation
- Populations
and patients
benefit
equitably
from new
approaches to
prevention,
diagnosis &
treatment
Subject to summative evaluation